The blog of Ashish Jha — physician, health policy researcher, and advocate for the notion that an ounce of data is worth a thousand pounds of opinion.

Monthly Archives: March 2014

I recently spoke to a quality measures development organization and it got me thinking — what makes a good doctor, and how do we measure it?

In thinking about this, I reflected on how far we have come on quality measurement. A decade or so ago, many physicians didn’t think the quality of their care could be measured and any attempt to do so was “bean counting” folly at best or destructive and dangerous at worse. Yet, in the last decade, we have seen a sea change. We have developed hundreds of quality measures and physicians are grumblingly accepting that quality measurement is here to stay. But the unease with quality measurement has not gone away and here’s why. If you ask “quality experts” what good care looks like for a patient with diabetes, they might apply the following criteria: good hemoglobin A1C control, regular checking of cholesterol, effective LDL control, smoking cessation counseling, and use of an ACE Inhibitor or ARB in subsets of patients with diabetes. Yet, when I think about great clinicians that I know – do I ask myself who achieves the best hemoglobin A1C control? No. Those measures – all evidence-based, all closely tied to better patient outcomes –don’t really feel like they measure the quality of the physician.

So where’s the disconnect? What does make a good doctor? Unsure, I asked Twitter:

Over 200 answers came rolling in. Listed below are the top 10. Top answer? Having empathy. #2? Being a good listener. It wasn’t until we get to #5 that we see “competent/effective”.

Even though the survey results above come from those I interact with on twitter, I suspect the results reflect what most Americans would want. As I read the discussions that followed, I came to conclude one thing: most people assume that physicians meet a threshold of intelligence, knowledge, and judgment and therefore, what differentiates good doctors from mediocre ones is the “soft” stuff.

It’s an interesting set of assumptions, but is it true? It is, at least somewhat. Most American physicians meet a basic threshold of competence – our system of licensure, board exams, etc. ensure that a vast majority of physicians have at least a basic level of knowledge. What most people don’t appreciate, however, is that even among this group, there are large, meaningful variations in capability and clinical judgment. And, of course, a small minority of people are able to get licensed without meeting the threshold at all. We all know these physicians – a small number to be sure — that are dangerously ineffective. We, the medical community, have been terrible about singling these physicians out and asking them to get better – or leave the profession.

In the twitter discussion, there was a second point raised by John Birkmeyer and that was likely on the minds of many respondents. He said “I’d want different things from my PCP and heart surgeon. Humility. Over-rated for the latter” John was raising a key distinction between what we want out of a physician (an Internist or a family practitioner) versus a surgeon. Yes, in order to be “good”, humility and empathy are important, even for cardiac surgeons. But when they are cutting into your sternum? You want them to be technically proficient and that trait trumps their ability (or lack thereof) to be empathic. Surgeons’ empathy and kindness matter – but it may not be as critical to their being an effective surgeon as their technical and team management skills. For Internists, effectiveness is much more dependent on their ability to listen, be empathic, and take patients’ values into consideration.

A final point. My favorite tweet came from Farzad Mostashari, who asked: “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?” In all the discussions about being a good doctor, we heard little about effective use of beta-blockers for heart disease, or good management of diabetes care. That’s the stuff we measure, and it’s important. We use them as part of the Physician Quality Reporting System (PQRS). But I’m not sure they really measure the quality of the physician. They measure quality of the system in which the physician practices. You can have a mediocre physician, but on a good team with excellent clinical support staff, those things get done. Even the smartest physician who knows the evidence perfectly can’t deliver consistently reliable care if there isn’t a system built around him or her to do so.

So, when it comes to thinking about ambulatory care quality – we should think about two sets of metrics: what it means to be a good doctor and what it means to work in a good system. In measuring doctor quality, we might focus on “soft” skills like empathy, which we can measure through patient experience surveys. But we also have to focus on intellectual skills, such as ability to make difficult diagnoses and emotional intelligence, such as the ability to collaborate and effectively lead teams – and we don’t really measure these things at all, erroneously assuming that all clinicians have them. For measuring good systems, we could use our current metrics such as whether they achieve good hypertension and diabetes control. We need to keep these two sets of metrics separate and not confuse one for the other. And, alas, for surgeons, we need a different approach yet. Yes, I still believe that humility and empathy go a long way – but these qualities are no substitute for sound judgment and a steady hand.

March 2nd through the 8th is National Patient Safety Awareness Week – I don’t really know what that means either. We seem to have a lot of these kinds of days and weeks – my daughters pointed out that March 4 was National Pancake Day – with resultant implications for our family meals. But back to patient safety. It is National Patient Safety Awareness Week, and in recognition, I thought it would be useful to talk about one organization that is doing so much to raise our awareness of the issues of patient safety. Which organization is this? Who seems to be leading the charge, reminding us of the urgent, unfinished agenda around patient safety? It’s an unlikely one: The Office of the Inspector General of the Department of Health and Human Services. Yes, the OIG. This oversight agency strikes fear into the hearts of bureaucrats: OIG usually goes after improper behavior of federal employees, investigates fraud, and makes sure your tax dollars are being used for the purposes Congress intended.

In 2006, Congress asked the OIG to examine how often “never events” occur and whether the Centers for Medicare and Medicaid Services (CMS) adequately denies payments for them. The OIG took this Congressional request to heart and has, at least in my mind, used it for far greater good: to begin to look at issues of patient safety far more broadly. Taken from one lens, the OIG’s approach makes sense: the federal government spends hundreds of billions of dollars on healthcare for older and disabled Americans and Congress obviously never intended those dollars pay for harmful care. So, the OIG thinks patient safety is part of its role in oversight, and thank goodness it does. Because in a world where patient safety gets a lot of discussion but much less action, the OIG keeps the issue on the front burner, reminding us of the human toll of inaction.

While the OIG has had multiple important reports in this area, the watershed one was their eye-opening November 2010 report. If you haven’t read at least the executive summary, you should. The OIG looked at care for a national sample of Medicare beneficiaries and what it found was unexpected: 13.5% of Medicare beneficiaries suffered an injury in the hospital that prolonged their hospital stay, caused permanent harm, or even death. An additional 13.5% of Medicare patients suffered “temporary” harm – such as an allergic reaction or hypoglycemia – things that are reversible and treatable, but quite problematic nonetheless. Taken together, these data suggest that 27% of older Americans suffer some sort of injury during their hospitalization – much higher than previous numbers.

There are three more statistics from the OIG report that should give us all pause: First, they estimate that unsafe care contributes to 180,000 deaths of Medicare beneficiaries each year. This is a stunningly high number. Second, Medicare pays at least an additional $4.4 billion to cover the costs of caring for these injuries. And finally, about half of these events are preventable based on today’s technology and know-how. I suspect that if we actually make safety a priority, many more events would become preventable over time. And yet, although hospitals are supposed to identify, study, and track adverse events, the OIG says it mostly isn’t happening. At least not in any systematic way.

This is all old news, of course, so on to new news: the OIG just released another excellent report, this time on harm in skilled nursing facilities (SNFs). While we have paid a lot of attention to acute hospitals, we have generally paid far less attention to what happens when patients leave. And, about 20% of Medicare patients, after discharge, go to a SNF. So, the OIG went looking at SNF care, and what they found is both unsurprising and quite disappointing: during their SNF stay, 22% of Medicare beneficiaries suffered a harm that prolonged stay, caused permanent harm, or even death. And, an additional 11% suffered temporary harm that could be reversed with a medical intervention. Physician reviewers considered 59% of these events to be preventable and these physician reviewers “attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care.” And these adverse events add an additional $2.8 Billion to Medicare spending. And remember, none of these financial calculations include the financial harm patients suffer because of lost work, family members having to take time off to provide additional care, etc.

It’s been 15 years since To Err is Human and patient safety has gone from a niche topic to something far more mainstream. We now recognize that safety is a huge problem. However, over the past few years, we have seen consistently disappointing data that we aren’t making much progress. It has caused many people to stop trying. Of course, we can’t publicly admit that we are giving up when the human toll is so high. So, instead, we are encouraging “voluntary reporting” that ignores most errors, using metrics to assess performance that don’t really reflect the safety of underlying care, and putting tiny incentives in place that aren’t meaningful enough to really change behavior. In 5 years, when we talk about the 20th anniversary of the To Err is Human report, will we wonder again why we have made so little progress?

The path forward, although difficult, is pretty clear. I’ve previously described a set of proposed solutions but in a nutshell, I think we should do three things: Measure and monitor adverse events in a systematic and robust way. This is increasingly possible with EHRs and we have described how before. Second, make safety data public. It will catalyze professional ethos, create real competition for safety, and force hospitals to get better. Third, put big incentives on the table so that there is a clear business case for safety. There are lots of ways to do it and are well described. And if we actually want to do this, we will have to reform our malpractice system so that these data can’t be turned into information for litigation. Finally, we need to move beyond hospital safety (despite having made so little progress in this arena) and start including safety in in a much broader context. As the OIG points out, there are lots of safety problems in post-acute care as well. That’s my wish list for what we need to do. I’m not sure it’s right, and others surely have better ideas. But we can’t be satisfied with our current efforts. And, thanks to the OIG, we are fully aware of the size and scope of the problem.

So, during Patient Safety Awareness Week, we should all take a moment to thank the Office of the Inspector General at HHS for reminding us that patient safety remains a pressing concern. Fixing it, of course, will require tough solutions and a lot of unhappy “stakeholders” who like the status quo. But, as the OIG reminds us, the human and financial costs of waiting is very high.